Provider Demographics
NPI:1356855589
Name:WATERVLIET PHARMACY INC
Entity type:Organization
Organization Name:WATERVLIET PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:RAMAKRISHNA
Authorized Official - Middle Name:
Authorized Official - Last Name:BURRAMUKKU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-201-6100
Mailing Address - Street 1:317 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WATERVLIET
Mailing Address - State:MI
Mailing Address - Zip Code:49098-9608
Mailing Address - Country:US
Mailing Address - Phone:269-201-6100
Mailing Address - Fax:269-201-6020
Practice Address - Street 1:317 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERVLIET
Practice Address - State:MI
Practice Address - Zip Code:49098-9608
Practice Address - Country:US
Practice Address - Phone:692-016-1002
Practice Address - Fax:269-201-6062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-27
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy